| NPI | 1639405335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA PA.200627) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9105242) |
| Enumeration Date | 2009-10-30 |
| Last Update Date | 2018-01-10 |