| NPI | 1669455010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102959) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 102959) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 102959) | |
| Enumeration Date | 2005-11-21 |
| Last Update Date | 2021-02-12 |