| NPI | 1164440392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C5-0000211) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: DE C50000211) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2016-01-07 |