| NPI | 1912057944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007715) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 001000407) |
| Enumeration Date | 2007-01-11 |
| Last Update Date | 2021-05-12 |