| NPI | 1073524443 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 103772) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: SC 2985) | |
| 363AM0700X Physician Assistant, Medical (Licence: NC 103772) | |
| Enumeration Date | 2006-08-11 |
| Last Update Date | 2023-04-07 |