| NPI | 1407051519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: DC PA030630) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110002800) |
| 363A00000X Physician Assistant (Licence: MD C0003517) | |
| Enumeration Date | 2007-06-19 |
| Last Update Date | 2009-12-04 |