| NPI | 1730160938 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA057703) |
| 363AM0700X Physician Assistant, Medical (Licence: MA PA5742) | |
| 363AM0700X Physician Assistant, Medical (Licence: GA 12/31/2006) | |
| Enumeration Date | 2005-11-07 |
| Last Update Date | 2016-08-19 |