| NPI | 1669991717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07915) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-09-10 |
| Last Update Date | 2018-11-01 |