NPI | 1912498130 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113282) |
Additional Taxonomies | 363A00000X Physician Assistant |
363AM0700X Physician Assistant, Medical (Licence: CT 4137) | |
Enumeration Date | 2018-05-23 |
Last Update Date | 2020-09-21 |