| NPI | 1316475619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: GA 8405) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2017-05-31 |
| Last Update Date | 2022-07-21 |