| NPI | 1114340163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-05738) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004461) |
| Enumeration Date | 2014-01-28 |
| Last Update Date | 2018-11-28 |