| NPI | 1346242443 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 103519) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 103519) |
| Enumeration Date | 2005-06-02 |
| Last Update Date | 2022-01-20 |