| NPI | 1366488926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-308) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID pa-308) |
| Enumeration Date | 2006-06-21 |
| Last Update Date | 2011-09-30 |