| NPI | 1295746196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 0753) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1271) |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2017-11-09 |