| NPI | 1851384770 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 010-05392) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX 1062273) |
| Enumeration Date | 2005-08-25 |
| Last Update Date | 2019-08-22 |