| NPI | 1114908795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2002001061) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9103253) |
| Enumeration Date | 2005-11-09 |
| Last Update Date | 2007-10-12 |