| NPI | 1457687717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 619) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 4536) |
| Enumeration Date | 2009-10-21 |
| Last Update Date | 2014-12-04 |