| NPI | 1780604181 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA001841L) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 001000165) |
| 363A00000X Physician Assistant (Licence: PA MA001841L) | |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2010-01-26 |