| NPI | 1639288764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT PA465) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 465) |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2012-09-24 |