| NPI | 1285119875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 1633) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2018-0090) |
| Enumeration Date | 2018-09-28 |
| Last Update Date | 2021-12-14 |