| NPI | 1407808314 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00806) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 0010-00806) |
| 363AM0700X Physician Assistant Medical (Licence: VA 0110001530) | |
| Enumeration Date | 2006-05-17 |
| Last Update Date | 2018-08-24 |