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 |