| NPI | 1265537021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC TL1940) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA002186L) |
| Enumeration Date | 2006-09-14 |
| Last Update Date | 2014-12-16 |