| NPI | 1073533410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00069) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 0010-00069) |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2023-03-27 |