| NPI | 1548710114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA OA003945) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA058624) |
| Enumeration Date | 2016-10-07 |
| Last Update Date | 2016-10-07 |