| NPI | 1720052681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA000323L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA001926L) |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2007-07-08 |