| NPI | 1508049354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110000124) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA001138L) |
| Enumeration Date | 2007-12-14 |
| Last Update Date | 2007-12-14 |