| NPI | 1366690265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001003954) |
| Additional Taxonomies | 235Z00000X Speech-Language Pathologist (Licence: PA SL008853) |
| 363AM0700X Physician Assistant Medical (Licence: NC 0010-03954) | |
| Enumeration Date | 2008-09-04 |
| Last Update Date | 2018-10-22 |