| NPI | 1659689628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 11159) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1095610) |
| Enumeration Date | 2010-09-23 |
| Last Update Date | 2022-12-14 |