| NPI | 1285797100 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004680) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-00591) |
| Enumeration Date | 2006-12-19 |
| Last Update Date | 2021-03-31 |