| NPI | 1023489663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 258563) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2015-10-08 |
| Last Update Date | 2024-10-01 |