| NPI | 1871577395 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 5141) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0001524) |
| Enumeration Date | 2005-11-30 |
| Last Update Date | 2019-11-05 |