| NPI | 1962459404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 103249) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 103249) |
| Enumeration Date | 2006-05-30 |
| Last Update Date | 2019-12-10 |