| NPI | 1295836831 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 508) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY 356) |
| Enumeration Date | 2006-09-26 |
| Last Update Date | 2016-09-26 |