| NPI | 1730370701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: WI 2179) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: IA 2189) |
| Enumeration Date | 2007-08-06 |
| Last Update Date | 2015-03-31 |