| NPI | 1306204870 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 06924) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: NY 019481) | |
| Enumeration Date | 2016-01-29 |
| Last Update Date | 2024-01-25 |