| NPI | 1851660013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA055273) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA002760) |
| Enumeration Date | 2011-12-17 |
| Last Update Date | 2011-12-17 |