| NPI | 1568668812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 102405) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 102405) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2007-06-25 |
| Last Update Date | 2019-08-22 |