| NPI | 1568627917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5547) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 533) |
| Enumeration Date | 2008-07-25 |
| Last Update Date | 2017-02-13 |