| NPI | 1558735878 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3046) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5586) |
| Enumeration Date | 2015-11-24 |
| Last Update Date | 2018-10-22 |