| NPI | 1235565813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA056308) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA003100) |
| Enumeration Date | 2013-09-16 |
| Last Update Date | 2013-09-16 |