| NPI | 1083658561 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11816) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 002835) |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2022-01-07 |