| NPI | 1225266158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102361) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC NC102361) |
| Enumeration Date | 2009-06-30 |
| Last Update Date | 2023-07-18 |