| NPI | 1205804440 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA249) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 249) |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2011-06-23 |