| NPI | 1225339518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02558) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110003375) |
| Enumeration Date | 2010-11-03 |
| Last Update Date | 2017-03-13 |