| NPI | 1124091632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 367) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 0311) |
| Enumeration Date | 2006-02-08 |
| Last Update Date | 2013-11-25 |