| NPI | 1396713269 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110002259) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 01189) |
| 363AS0400X Physician Assistant, Surgical (Licence: VA 0110002259) | |
| Enumeration Date | 2006-03-08 |
| Last Update Date | 2013-01-31 |