| NPI | 1477096766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55582) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OH 50.004908RX) |
| Enumeration Date | 2016-11-18 |
| Last Update Date | 2018-09-25 |