| NPI | 1477905354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2582) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SC TL2582) |
| Enumeration Date | 2016-07-05 |
| Last Update Date | 2021-01-12 |