| NPI | 1316909583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-10960) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2021-02-18 |