| NPI | 1447235767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA000496L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA002121) |
| Enumeration Date | 2005-12-09 |
| Last Update Date | 2008-03-03 |