| NPI | 1417043837 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6804) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO PAL2326) |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2023-09-22 |