| NPI | 1932452158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9106969) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.008904) |
| 363A00000X Physician Assistant (Licence: CA PA59144) | |
| 363A00000X Physician Assistant (Licence: NC 001012360) | |
| 363AM0700X Physician Assistant, Medical (Licence: NY 016134-1) | |
| Enumeration Date | 2012-10-25 |
| Last Update Date | 2022-12-20 |