| NPI | 1669043469 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110-008478) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0008019) |
| Enumeration Date | 2021-07-02 |
| Last Update Date | 2022-03-26 |