| NPI | 1720075211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 3603) |
| Enumeration Date | 2005-09-30 |
| Last Update Date | 2015-02-02 |