| NPI | 1467082743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12416) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110007263) |
| Enumeration Date | 2020-01-25 |
| Last Update Date | 2023-12-13 |