| NPI | 1083918189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003642) |
| Enumeration Date | 2011-01-04 |
| Last Update Date | 2021-04-09 |