NPI | 1659811644 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9110336) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 60741890) |
Enumeration Date | 2017-02-24 |
Last Update Date | 2017-10-13 |