| NPI | 1225078728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 4134) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AL PA-359) |
| Enumeration Date | 2006-06-07 |
| Last Update Date | 2012-09-05 |