| NPI | 1629176615 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 200564) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL 1069238) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2013-04-09 |