| NPI | 1588659387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 103541) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC A398) |
| 363A00000X Physician Assistant (Licence: TN 0009) | |
| 363A00000X Physician Assistant (Licence: GA 2669) | |
| Enumeration Date | 2005-09-18 |
| Last Update Date | 2009-12-23 |