| NPI | 1295238814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12438) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA.1323) |
| Enumeration Date | 2018-03-09 |
| Last Update Date | 2023-04-27 |