| NPI | 1417990904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SC 5248) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA000359L) |
| Enumeration Date | 2006-06-13 |
| Last Update Date | 2024-07-09 |