| NPI | 1427042415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA000422L) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA MA000422L) |
| 363AS0400X Physician Assistant Surgical (Licence: PA MA000422L) | |
| Enumeration Date | 2005-09-06 |
| Last Update Date | 2010-09-14 |