| NPI | 1215986914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 0509 P) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601005057) |
| Enumeration Date | 2006-05-09 |
| Last Update Date | 2007-11-29 |