| NPI | 1720312168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08114) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2009-10-01 |
| Last Update Date | 2022-07-27 |