| NPI | 1770568503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102646) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110001427) |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2021-04-30 |