| NPI | 1841573805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 7603) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 2019) |
| Enumeration Date | 2011-09-26 |
| Last Update Date | 2018-08-08 |