| NPI | 1104460096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10147) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9112730) |
| Enumeration Date | 2019-11-04 |
| Last Update Date | 2021-10-13 |