| NPI | 1891884300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA000213L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA059380) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2022-04-26 |