| NPI | 1366560765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA053083) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 2305) |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2018-01-19 |