| NPI | 1215281282 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 002355) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1680) |
| Enumeration Date | 2012-10-30 |
| Last Update Date | 2015-07-30 |