| NPI | 1477502417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 327325) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101508) |
| Enumeration Date | 2006-05-08 |
| Last Update Date | 2021-09-29 |