| NPI | 1023664109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA7136) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA7136) |
| Enumeration Date | 2019-08-14 |
| Last Update Date | 2019-12-20 |