| NPI | 1043385123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102728) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC PA555) |
| Enumeration Date | 2006-11-22 |
| Last Update Date | 2025-12-03 |