| NPI | 1023081668 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 100569) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 0428) |
| Enumeration Date | 2006-02-13 |
| Last Update Date | 2022-03-25 |