| NPI | 1255665980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 006976) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1445) |
| Enumeration Date | 2009-09-29 |
| Last Update Date | 2013-12-04 |