| NPI | 1851462154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06109) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 281) |
| Enumeration Date | 2006-11-10 |
| Last Update Date | 2016-04-01 |