| NPI | 1972809309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08024) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AL TA-1724) |
| Enumeration Date | 2011-02-02 |
| Last Update Date | 2021-08-11 |