| NPI | 1184952855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA054209) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA003110) |
| Enumeration Date | 2009-11-18 |
| Last Update Date | 2023-07-24 |