| NPI | 1710319553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DC PA030795) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: MD C0005138) |
| 363A00000X Physician Assistant (Licence: MD C0005138) | |
| 363AM0700X Physician Assistant Medical (Licence: MD C0005138) | |
| Enumeration Date | 2013-08-03 |
| Last Update Date | 2024-10-25 |