| NPI | 1235248824 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1881) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 310) |
| Enumeration Date | 2006-08-29 |
| Last Update Date | 2014-12-02 |