| NPI | 1275819633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03180) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SC 2006) |
| Enumeration Date | 2011-10-31 |
| Last Update Date | 2021-07-30 |