| NPI | 1346203049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 885) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 001824) |
| Enumeration Date | 2006-04-11 |
| Last Update Date | 2017-02-02 |