| NPI | 1891159695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 337259) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 54909) |
| 363A00000X Physician Assistant (Licence: GA 7968) | |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2016-04-07 |
| Last Update Date | 2023-08-30 |