| NPI | 1457663593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA PA.200421) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA pending graduation) |
| Enumeration Date | 2010-07-06 |
| Last Update Date | 2014-02-17 |