| NPI | 1487950127 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2011003916) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 1097328) |
| Enumeration Date | 2011-01-27 |
| Last Update Date | 2013-02-04 |