| NPI | 1073985230 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA057959) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA003666) |
| Enumeration Date | 2015-10-28 |
| Last Update Date | 2020-08-31 |