NPI | 1154472256 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 2005) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 14822) |
363AM0700X Physician Assistant, Medical (Licence: ID 2005) | |
Enumeration Date | 2007-01-15 |
Last Update Date | 2023-07-10 |