| NPI | 1609509363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0019004815) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: VA 0019004815) |
| Enumeration Date | 2022-07-08 |
| Last Update Date | 2022-07-18 |