| NPI | 1396031514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09477) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003595) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2011-06-27 |
| Last Update Date | 2021-07-15 |