| NPI | 1588830194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE c5-0005942) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA ma050950) |
| Enumeration Date | 2008-05-03 |
| Last Update Date | 2019-01-28 |