| NPI | 1609883016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: GA 002525) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: GA 002525) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2007-07-08 |