| NPI | 1366715625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD C0001029) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA002128L) |
| Enumeration Date | 2012-02-17 |
| Last Update Date | 2013-03-05 |