| NPI | 1356484075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001000151) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2697) |
| 363A00000X Physician Assistant (Licence: GA 4998) | |
| Enumeration Date | 2007-02-14 |
| Last Update Date | 2022-11-21 |