| NPI | 1639446180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DC PA031106) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015355) |
| Enumeration Date | 2011-11-29 |
| Last Update Date | 2019-01-30 |