| NPI | 1134757529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9679) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 9679) |
| Enumeration Date | 2020-03-31 |
| Last Update Date | 2020-04-08 |