| NPI | 1558770099 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA056969) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA003335) |
| Enumeration Date | 2014-08-08 |
| Last Update Date | 2014-08-08 |