| NPI | 1639263775 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102410) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 102410) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2019-11-26 |