| NPI | 1588614176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1386) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-01599) |
| Enumeration Date | 2006-05-12 |
| Last Update Date | 2015-10-27 |