| NPI | 1730508896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2101) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SC 2101) |
| Enumeration Date | 2014-04-15 |
| Last Update Date | 2020-04-09 |