| NPI | 1952355331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA054316) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9103708) |
| 363A00000X Physician Assistant (Licence: WA PA60289681) | |
| Enumeration Date | 2006-05-20 |
| Last Update Date | 2013-06-27 |