| NPI | 1487398293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 2819) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 116294) |
| Enumeration Date | 2022-04-27 |
| Last Update Date | 2022-10-03 |