| NPI | 1407810252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA 66) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MA 66) |
| Enumeration Date | 2006-04-17 |
| Last Update Date | 2007-07-08 |