NPI | 1356484075 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001000151) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2697) |
363A00000X Physician Assistant (Licence: GA 4998) | |
Enumeration Date | 2007-02-14 |
Last Update Date | 2022-11-21 |