| NPI | 1659308138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA051047) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C50000393) |
| Enumeration Date | 2006-06-28 |
| Last Update Date | 2011-09-07 |