| NPI | 1508928474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 02220) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AL P.A.-1) |
| Enumeration Date | 2006-12-15 |
| Last Update Date | 2007-07-08 |