| NPI | 1801992680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA000665L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA000075L) |
| Enumeration Date | 2006-09-16 |
| Last Update Date | 2019-11-26 |