| NPI | 1942253265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 10-01305) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA050937) |
| 363A00000X Physician Assistant (Licence: PA OA000500L) | |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2020-10-29 |