| NPI | 1336102060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 101216) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 011820) |
| Enumeration Date | 2006-04-12 |
| Last Update Date | 2022-06-23 |