| NPI | 1952418998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110002396) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 001000259) |
| Enumeration Date | 2006-08-24 |
| Last Update Date | 2016-03-04 |