| NPI | 1144254418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 10-95) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015190) |
| 363A00000X Physician Assistant (Licence: OH 50003018) | |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2017-02-10 |