| NPI | 1194725457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9102852) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA.915) |
| Enumeration Date | 2005-07-28 |
| Last Update Date | 2017-01-05 |