| NPI | 1275770166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA 1084360) |
| Enumeration Date | 2009-01-14 |
| Last Update Date | 2014-06-25 |