| NPI | 1013167956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 0134) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 1588) |
| Enumeration Date | 2008-09-29 |
| Last Update Date | 2013-07-31 |