NPI | 1104808674 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 103761) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 010847) |
363AS0400X Physician Assistant, Surgical (Licence: PA MA052674) | |
Enumeration Date | 2005-11-18 |
Last Update Date | 2016-10-26 |