| NPI | 1114917168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-500) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA500) |
| Enumeration Date | 2005-10-21 |
| Last Update Date | 2014-10-22 |