| NPI | 1508817495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA000713) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA050780) |
| Enumeration Date | 2006-05-15 |
| Last Update Date | 2007-10-31 |