| NPI | 1467595496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 100823) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC PA2072) |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2019-12-20 |