| NPI | 1043650518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 5671) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-004291) |
| Enumeration Date | 2013-06-28 |
| Last Update Date | 2020-04-10 |