| NPI | 1205078458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 66731) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 2752) |
| Enumeration Date | 2009-04-02 |
| Last Update Date | 2018-06-13 |