| NPI | 1871510883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MA 1876) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA057997) |
| Enumeration Date | 2006-07-16 |
| Last Update Date | 2015-12-11 |