| NPI | 1417103326 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001005342) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0003685) |
| Enumeration Date | 2008-08-12 |
| Last Update Date | 2015-07-15 |