| NPI | 1184610644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03028) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 003549) |
| Enumeration Date | 2005-09-21 |
| Last Update Date | 2014-11-14 |