| NPI | 1033515358 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05839) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 3002) |
| 363A00000X Physician Assistant (Licence: VA 0110-004789) | |
| Enumeration Date | 2014-11-13 |
| Last Update Date | 2023-04-07 |