| NPI | 1548204126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA GA5085) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA002318L) |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2014-01-31 |