| NPI | 1487633590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102270) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 102270) |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 102270) | |
| Enumeration Date | 2006-01-17 |
| Last Update Date | 2011-05-02 |