| NPI | 1629264882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MT 344) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WY 340) |
| Enumeration Date | 2007-09-21 |
| Last Update Date | 2007-09-21 |