| NPI | 1548532187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 1162) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003790) |
| Enumeration Date | 2012-01-28 |
| Last Update Date | 2016-12-09 |