| NPI | 1548211444 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102071) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 102071) |
| Enumeration Date | 2006-05-15 |
| Last Update Date | 2021-07-15 |