| NPI | 1518933373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 1407) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 001407) |
| Enumeration Date | 2006-02-23 |
| Last Update Date | 2015-08-20 |