| NPI | 1679845713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA4339) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4977) |
| 363A00000X Physician Assistant (Licence: TN PA2390) | |
| 363A00000X Physician Assistant (Licence: NC 0010-03656) | |
| 363A00000X Physician Assistant (Licence: RI PA00633) | |
| 363A00000X Physician Assistant (Licence: NH 0877) | |
| Enumeration Date | 2012-02-06 |
| Last Update Date | 2022-12-15 |