| NPI | 1063485001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: VA 0110840307) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 101941) |
| Enumeration Date | 2006-02-09 |
| Last Update Date | 2016-09-21 |