| NPI | 1356694566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA057609) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA002950) |
| Enumeration Date | 2012-10-25 |
| Last Update Date | 2016-10-05 |