| NPI | 1144510538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA051903) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA004216) |
| Enumeration Date | 2011-04-19 |
| Last Update Date | 2018-01-29 |