| NPI | 1477570182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110001834) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0002904) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2013-02-20 |