| NPI | 1508472622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9116353) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PA 1177293) |
| Enumeration Date | 2020-09-23 |
| Last Update Date | 2022-11-15 |