| NPI | 1477955789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 1848) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 074862) |
| Enumeration Date | 2014-09-17 |
| Last Update Date | 2014-09-17 |