| NPI | 1730161043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 4651) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 000864) |
| Enumeration Date | 2005-11-14 |
| Last Update Date | 2011-10-12 |