| NPI | 1518961937 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02312) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC A493) |
| Enumeration Date | 2005-06-13 |
| Last Update Date | 2014-10-16 |