| NPI | 1790736908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0003197) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002154) |
| Enumeration Date | 2006-05-12 |
| Last Update Date | 2008-05-22 |