| NPI | 1477501229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003872) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 103652) |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2016-06-13 |