| NPI | 1164480935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 3465) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1038) |
| Enumeration Date | 2006-05-02 |
| Last Update Date | 2015-01-13 |