| NPI | 1003381633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 7284) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AZ 7284) |
| 363AS0400X Physician Assistant Surgical (Licence: AZ 7284) | |
| Enumeration Date | 2018-10-10 |
| Last Update Date | 2018-10-10 |