| NPI | 1275845190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01946) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-01946) |
| Enumeration Date | 2010-07-08 |
| Last Update Date | 2019-01-03 |