| NPI | 1215172697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110005363) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-01591) |
| Enumeration Date | 2008-12-12 |
| Last Update Date | 2017-04-25 |