| NPI | 1679540587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1652) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.200003) |
| Enumeration Date | 2006-03-01 |
| Last Update Date | 2014-09-19 |