| NPI | 1467563080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110001800) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD c0002823) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2011-04-05 |