| NPI | 1649705278 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07197) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 00107197) |
| Enumeration Date | 2017-04-20 |
| Last Update Date | 2022-11-02 |