| NPI | 1124136304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0003514) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002440) |
| Enumeration Date | 2006-08-28 |
| Last Update Date | 2011-05-27 |