| NPI | 1215273925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 304717) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004037) |
| Enumeration Date | 2012-12-27 |
| Last Update Date | 2023-06-05 |