| NPI | 1053827196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0006689) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0006689) |
| Enumeration Date | 2017-12-27 |
| Last Update Date | 2018-03-17 |