| NPI | 1275587255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102765) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 102765) | |
| Enumeration Date | 2006-05-22 |
| Last Update Date | 2023-03-07 |