| NPI | 1558307397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001000344) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: NC 2389) |
| 363A00000X Physician Assistant (Licence: SC 1042) | |
| Enumeration Date | 2006-06-21 |
| Last Update Date | 2020-10-25 |