| NPI | 1881957306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004441) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 0010-03591) |
| Enumeration Date | 2012-06-19 |
| Last Update Date | 2020-05-07 |