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 |