| NPI | 1659322279 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C50000481) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA052140) |
| Enumeration Date | 2006-05-16 |
| Last Update Date | 2008-05-29 |