| NPI | 1518947548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL 9103913) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AL PA-365) |
| 363AM0700X Physician Assistant Medical (Licence: NC 102483) | |
| 363A00000X Physician Assistant (Licence: MD C0002449) | |
| Enumeration Date | 2006-01-17 |
| Last Update Date | 2007-11-22 |