| NPI | 1306804620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA003389L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9114542) |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2023-01-13 |