| NPI | 1659370252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 100548) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 100548) |
| Enumeration Date | 2005-07-18 |
| Last Update Date | 2022-02-09 |