| NPI | 1376776401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA056253) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0004027) |
| Enumeration Date | 2009-08-24 |
| Last Update Date | 2017-04-27 |