| NPI | 1417055419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA052686) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA TMA051656) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2010-10-04 |