| NPI | 1902864028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA052218) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA002463) |
| Enumeration Date | 2006-05-01 |
| Last Update Date | 2012-02-09 |