| NPI | 1508845421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA1146) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C500000139) |
| Enumeration Date | 2006-01-10 |
| Last Update Date | 2014-12-29 |