| NPI | 1316052111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110002571) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0006682) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 102256) | |
| 363AM0700X Physician Assistant, Medical (Licence: VA 0110002571) | |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2024-01-26 |