| 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 |