| NPI | 1770687311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 103002) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1437) |
| Enumeration Date | 2006-09-12 |
| Last Update Date | 2019-09-17 |