| NPI | 1972655520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C00940) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C00940) |
| Enumeration Date | 2007-01-16 |
| Last Update Date | 2013-06-19 |