NPI | 1750634507 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 9096169-1206) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 016175) |
Enumeration Date | 2012-10-17 |
Last Update Date | 2023-02-07 |