| NPI | 1790728145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102375) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2018-05-17 |