| NPI | 1629321021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004485) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2210) |
| Enumeration Date | 2012-10-23 |
| Last Update Date | 2017-02-23 |