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 (Licence: NC 0010-10515) | |
363AM0700X Physician Assistant, Medical | |
Enumeration Date | 2019-08-09 |
Last Update Date | 2020-09-15 |