| NPI | 1982031803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AL 916) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA 200809) |
| Enumeration Date | 2013-10-09 |
| Last Update Date | 2015-11-09 |