| NPI | 1912145970 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1901) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002948) |
| Enumeration Date | 2009-01-29 |
| Last Update Date | 2014-02-18 |