| NPI | 1508951690 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0004627) | 
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0002451) | 
| 363A00000X Physician Assistant (Licence: PA MA0532470) | |
| Enumeration Date | 2006-10-04 | 
| Last Update Date | 2016-03-28 |