| NPI | 1891737649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-62036) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 004617) |
| 363A00000X Physician Assistant (Licence: FL PA9103979) | |
| Enumeration Date | 2006-06-12 |
| Last Update Date | 2021-09-20 |