| NPI | 1881685642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-204) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA00575) |
| Enumeration Date | 2005-11-02 |
| Last Update Date | 2011-03-16 |