| NPI | 1700985769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C5-0001013) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110001154) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2015-08-14 |