| NPI | 1861998676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA059732) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2018-04-02 |
| Last Update Date | 2019-06-11 |