| NPI | 1558916114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0015-10515) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 024267) |
| 363A00000X Physician Assistant (Licence: GA 9879) | |
| 363AM0700X Physician Assistant, Medical | |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-10515) | |
| Enumeration Date | 2019-08-09 |
| Last Update Date | 2025-08-12 |