| NPI | 1518195932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA3784) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AK 2061) |
| Enumeration Date | 2009-06-24 |
| Last Update Date | 2013-11-05 |