| NPI | 1245516459 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110003771) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-10218) |
| 363A00000X Physician Assistant (Licence: MI 5601010944) | |
| 363A00000X Physician Assistant (Licence: IL 085.008777) | |
| 363A00000X Physician Assistant (Licence: NY 027730) | |
| 363A00000X Physician Assistant (Licence: OH 50.007382) | |
| Enumeration Date | 2011-11-01 |
| Last Update Date | 2022-12-29 |