| NPI | 1982843306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA1075L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA001075L) |
| Enumeration Date | 2009-02-09 |
| Last Update Date | 2013-05-10 |