| NPI | 1578584280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NE 611) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 611) |
| Enumeration Date | 2006-07-21 |
| Last Update Date | 2018-05-15 |