| NPI | 1578540498 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: ID PA402) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-402) |
| Enumeration Date | 2005-12-30 |
| Last Update Date | 2010-05-28 |