| NPI | 1255566345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06252) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9104575) |
| Enumeration Date | 2009-05-19 |
| Last Update Date | 2019-01-09 |