| NPI | 1619934700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NC 0010-03945) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: SC 2854SC) |
| Enumeration Date | 2006-05-01 |
| Last Update Date | 2013-01-16 |