| NPI | 1780648253 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA9101223) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101223) |
| Enumeration Date | 2006-04-13 |
| Last Update Date | 2009-02-04 |