| NPI | 1740270446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE NE00935) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 935) |
| Enumeration Date | 2005-10-24 |
| Last Update Date | 2011-01-27 |