| NPI | 1649271313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA000378L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA000252L) |
| Enumeration Date | 2005-08-03 |
| Last Update Date | 2009-04-08 |