| NPI | 1275739724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02449) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002419) |
| Enumeration Date | 2007-06-22 |
| Last Update Date | 2023-01-27 |