| NPI | 1619066024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MO 117542) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MO 117542) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2009-09-22 |