| NPI | 1508946104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102367) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110001125) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2024-08-06 |