| NPI | 1629384268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001004408) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1604) |
| Enumeration Date | 2010-08-20 |
| Last Update Date | 2017-02-20 |