| NPI | 1295081701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA057596) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: PA TEI001201) |
| Enumeration Date | 2012-08-02 |
| Last Update Date | 2015-06-03 |