| NPI | 1548400658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA OA000770) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA001759-L) |
| Enumeration Date | 2009-03-02 |
| Last Update Date | 2011-07-19 |