| NPI | 1093750093 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102627) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9110455) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 102627) | |
| 363AM0700X Physician Assistant, Medical (Licence: SC A545) | |
| Enumeration Date | 2006-06-17 |
| Last Update Date | 2022-05-06 |