| NPI | 1215927512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA055178) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: DE C5-0000358) |
| 363A00000X Physician Assistant (Licence: DE C5-0000358) | |
| Enumeration Date | 2005-10-27 |
| Last Update Date | 2012-05-28 |