| NPI | 1972503449 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102593) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 102593) |
| Enumeration Date | 2005-07-27 |
| Last Update Date | 2013-07-11 |