| NPI | 1801346648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5873) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 003659) |
| Enumeration Date | 2016-10-05 |
| Last Update Date | 2016-10-05 |