| NPI | 1649210774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 001703) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 1220) |
| Enumeration Date | 2006-06-07 |
| Last Update Date | 2008-04-25 |