| NPI | 1114991916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00517) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110840725) |
| Enumeration Date | 2006-02-16 |
| Last Update Date | 2023-03-07 |