| NPI | 1972745321 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106423) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110002983) |
| Enumeration Date | 2009-04-01 |
| Last Update Date | 2020-01-02 |