| NPI | 1689966012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-04726) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.200439) |
| Enumeration Date | 2011-05-04 |
| Last Update Date | 2022-08-23 |