| NPI | 1558377580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 556) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 001184) |
| Enumeration Date | 2006-07-31 |
| Last Update Date | 2008-03-12 |