| NPI | 1205066453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01907) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003334) |
| Enumeration Date | 2009-07-22 |
| Last Update Date | 2022-08-19 |