| NPI | 1841660073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 019143) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60960732) |
| Enumeration Date | 2015-09-30 |
| Last Update Date | 2020-12-17 |