| NPI | 1861772295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: VA 0110840340) |
| Additional Taxonomies | 247200000X Technician, Other |
| Enumeration Date | 2011-08-17 |
| Last Update Date | 2013-01-11 |