| NPI | 1124435318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5502) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0005514) |
| Enumeration Date | 2014-07-19 |
| Last Update Date | 2015-10-29 |