| NPI | 1629583521 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9808) |
| Additional Taxonomies | 376K00000X Nurse's Aide (Licence: GA CN0030039899) |
| Enumeration Date | 2017-12-13 |
| Last Update Date | 2020-08-11 |