| NPI | 1811060213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA051006) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C50000132) |
| Enumeration Date | 2006-11-16 |
| Last Update Date | 2015-06-30 |