| NPI | 1407221302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA5539) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5539) |
| Enumeration Date | 2015-12-03 |
| Last Update Date | 2020-09-18 |