| NPI | 1376626150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-835) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 3802) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 3802) | |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2016-09-28 |