| NPI | 1548253149 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA053584) |
| Additional Taxonomies | 171W00000X Contractor (Licence: PA RT002530A) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2005-08-30 |
| Last Update Date | 2013-03-06 |