| NPI | 1124414693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05706) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 6039) |
| Enumeration Date | 2015-04-12 |
| Last Update Date | 2022-11-15 |