| NPI | 1467973511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA6155) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MA PA6155) |
| Enumeration Date | 2017-06-29 |
| Last Update Date | 2019-02-14 |