| NPI | 1477640654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110002562) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA052557) |
| Enumeration Date | 2006-10-06 |
| Last Update Date | 2012-05-09 |