| NPI | 1790716256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA OA000445L) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA003138L) |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2007-08-19 |