| NPI | 1366603797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003713) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-01389) |
| Enumeration Date | 2008-06-18 |
| Last Update Date | 2015-07-06 |