| NPI | 1700935699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1194) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 103958) |
| Enumeration Date | 2007-01-09 |
| Last Update Date | 2011-05-10 |