NPI | 1093104945 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110-004782) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 001005491) |
Enumeration Date | 2015-01-15 |
Last Update Date | 2021-08-26 |