| NPI | 1578547949 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 3345) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-03548) |
| Enumeration Date | 2005-11-30 |
| Last Update Date | 2012-07-31 |