| NPI | 1629330006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03570) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2012-06-12 |
| Last Update Date | 2019-03-12 |