| NPI | 1225055791 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110840723) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA002574L) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2012-11-05 |