| NPI | 1679831259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA057207) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2012-05-02 |
| Last Update Date | 2015-03-11 |