| NPI | 1750371605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102720) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 102720) |
| Enumeration Date | 2005-10-24 |
| Last Update Date | 2025-08-14 |