| NPI | 1811138126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12856) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002854) |
| Enumeration Date | 2009-03-16 |
| Last Update Date | 2023-02-07 |