| NPI | 1275530156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 962946861206) |
| Additional Taxonomies | 208D00000X General Practice (Licence: UT 294686-1206) |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2012-09-11 |