| NPI | 1932168473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102658) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 84047) |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 84047) | |
| Enumeration Date | 2006-03-22 |
| Last Update Date | 2020-10-29 |