| NPI | 1477961225 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 6653) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 11580) |
| Enumeration Date | 2014-07-24 |
| Last Update Date | 2017-04-05 |