| NPI | 1821247602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA053532) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NH 0744) |
| Enumeration Date | 2008-09-16 |
| Last Update Date | 2015-12-18 |