| NPI | 1245253004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: VA 0110002566) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WY 335) |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2007-12-21 |