| NPI | 1740394782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 1047509) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL 1047509) |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2018-06-06 |