| NPI | 1518207539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0004941) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MD C0004941) |
| 363AS0400X Physician Assistant Surgical (Licence: DE C5-0000842) | |
| Enumeration Date | 2013-02-28 |
| Last Update Date | 2016-12-14 |