| NPI | 1346593548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA055742) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 001005365) |
| Enumeration Date | 2012-10-25 |
| Last Update Date | 2018-06-12 |