| NPI | 1659027217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12270) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9115717) |
| Enumeration Date | 2022-02-23 |
| Last Update Date | 2022-05-25 |