| NPI | 1477534469 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2091) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1057840) |
| Enumeration Date | 2005-11-08 |
| Last Update Date | 2016-06-24 |