| NPI | 1386821759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA1482) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care |
| Enumeration Date | 2008-01-28 |
| Last Update Date | 2024-07-17 |