| NPI | 1598191165 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110-004370) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-04350) |
| Enumeration Date | 2013-09-16 |
| Last Update Date | 2013-09-18 |