| NPI | 1982857702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-986) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 7164781-1206) |
| Enumeration Date | 2008-10-23 |
| Last Update Date | 2016-02-02 |