| NPI | 1952338485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL 9104510) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 01108408409) |
| Enumeration Date | 2006-06-28 |
| Last Update Date | 2012-08-01 |