| NPI | 1497781389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 553) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 0329) |
| Enumeration Date | 2006-06-23 |
| Last Update Date | 2009-10-21 |