| NPI | 1356314843 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA638) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NV PA882) |
| Enumeration Date | 2006-02-07 |
| Last Update Date | 2013-05-08 |