| NPI | 1043367170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-04921) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 1073868) |
| Enumeration Date | 2007-01-04 |
| Last Update Date | 2025-01-03 |