| NPI | 1558668780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: OH 50.005899RX) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 0010-02782) |
| 363AM0700X Physician Assistant Medical (Licence: IN 10002678A) | |
| Enumeration Date | 2011-02-24 |
| Last Update Date | 2020-05-21 |