| NPI | 1023497880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110005989) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05866) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-05886) | |
| 363AM0700X Physician Assistant, Medical (Licence: MI 5601004169) | |
| Enumeration Date | 2015-05-27 |
| Last Update Date | 2019-01-03 |