| NPI | 1306998216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 104064) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 104064) |
| Enumeration Date | 2007-01-18 |
| Last Update Date | 2022-01-27 |