| NPI | 1255780375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06556) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C06166) |
| Enumeration Date | 2016-06-09 |
| Last Update Date | 2017-02-13 |