| NPI | 1811331168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9149) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 016522) |
| Enumeration Date | 2013-04-17 |
| Last Update Date | 2019-12-03 |