| NPI | 1285788679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 103971) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NC 103971) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 145009) | |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2023-03-07 |