| NPI | 1063704724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110008700) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 1097195) |
| Enumeration Date | 2011-05-12 |
| Last Update Date | 2023-12-14 |