| NPI | 1982716585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00359) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 021664) |
| 363AM0700X Physician Assistant, Medical (Licence: SC 1020) | |
| 363AM0700X Physician Assistant, Medical (Licence: NC 001000359) | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2021-11-23 |