| NPI | 1811904006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004190) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 104127) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2016-06-23 |