| NPI | 1578755641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 5765) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110009945) |
| 363A00000X Physician Assistant (Licence: CO PA-3411) | |
| Enumeration Date | 2007-08-13 |
| Last Update Date | 2024-11-28 |