| NPI | 1174580534 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110001830) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NCCPA1027623) |
| Enumeration Date | 2006-04-28 |
| Last Update Date | 2007-07-08 |