| NPI | 1083653745 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 103055) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2006004610) |
| Enumeration Date | 2006-06-06 |
| Last Update Date | 2021-10-07 |