| NPI | 1235639196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 7097) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-07865) |
| Enumeration Date | 2018-02-17 |
| Last Update Date | 2018-06-20 |