| NPI | 1275824617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC TL1654) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2011-04-19 |
| Last Update Date | 2011-06-10 |