| NPI | 1548553712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA054510) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA002568) |
| Enumeration Date | 2011-05-20 |
| Last Update Date | 2015-12-23 |