| NPI | 1255955837 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061589) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-05-30 |
| Last Update Date | 2021-01-16 |