| NPI | 1063477370 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NC 104184) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: NC 104184) |
| Enumeration Date | 2006-04-19 |
| Last Update Date | 2022-07-21 |