| NPI | 1811259765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001003557) |
| Additional Taxonomies | 282N00000X General Acute Care Hospital |
| Enumeration Date | 2012-06-15 |
| Last Update Date | 2023-10-30 |