| NPI | 1114676517 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063483) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA006067) |
| Enumeration Date | 2022-03-22 |
| Last Update Date | 2022-03-22 |