| NPI | 1669411708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01168) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA AP 2040) |
| Enumeration Date | 2006-06-05 |
| Last Update Date | 2008-05-22 |