| NPI | 1053424598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 101079) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004396) |
| 363AM0700X Physician Assistant Medical (Licence: NC 101079) | |
| Enumeration Date | 2006-08-17 |
| Last Update Date | 2022-08-24 |