| NPI | 1538717467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 211D00000X Assistant, Podiatric (Licence: PR 383-P.A.) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PR 383-P.A.) |
| 363AS0400X Physician Assistant Surgical (Licence: PR 383-P.A.) | |
| Enumeration Date | 2019-09-04 |
| Last Update Date | 2019-09-04 |