| NPI | 1164496352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA000092L) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA00310L) |
| Enumeration Date | 2006-02-14 |
| Last Update Date | 2009-02-17 |