| NPI | 1063402006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NC 102171) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: FL PA9102837) |
| Enumeration Date | 2005-10-21 |
| Last Update Date | 2021-04-05 |