| NPI | 1134507734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110002105) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 103779) |
| Enumeration Date | 2015-05-14 |
| Last Update Date | 2015-05-15 |