| NPI | 1912092842 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02529) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110008498) |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2024-02-06 |