| NPI | 1780859900 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01898) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 012197) |
| Enumeration Date | 2008-04-29 |
| Last Update Date | 2016-03-24 |