| NPI | 1548318223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1839) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1057877 NCCPA) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2021-06-30 |