| NPI | 1639150238 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SC 2013) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC P103179) |
| Enumeration Date | 2005-11-10 |
| Last Update Date | 2020-11-11 |