| NPI | 1609141548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: DC PA030892) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110003744) |
| 363A00000X Physician Assistant (Licence: MD C04530) | |
| Enumeration Date | 2012-03-10 |
| Last Update Date | 2013-05-29 |