| NPI | 1417257908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-27456) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NM PA2012-0061) |
| Enumeration Date | 2010-10-29 |
| Last Update Date | 2014-03-31 |