| NPI | 1902823537 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110840811) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 02814) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2012-11-01 |