| NPI | 1992008825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA054542) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA002530) |
| Enumeration Date | 2010-12-15 |
| Last Update Date | 2010-12-15 |