| NPI | 1245453091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003717) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-00843) |
| Enumeration Date | 2007-04-10 |
| Last Update Date | 2012-01-05 |