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 |