| NPI | 1659557973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 008736) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA-TF-0183) |
| Enumeration Date | 2008-01-16 |
| Last Update Date | 2021-10-12 |