| NPI | 1518261155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02621) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-02621) |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-02621) | |
| Enumeration Date | 2010-12-22 |
| Last Update Date | 2019-08-07 |