| NPI | 1598263162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9110866) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 11006400) |
| Enumeration Date | 2018-01-29 |
| Last Update Date | 2020-04-07 |