| NPI | 1225223704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110002600) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: VA 0110002600) |
| 363A00000X Physician Assistant (Licence: VA 0110002600) | |
| Enumeration Date | 2007-09-07 |
| Last Update Date | 2019-10-03 |