| NPI | 1972958353 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9112435) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA.1143) |
| Enumeration Date | 2016-05-04 |
| Last Update Date | 2020-10-26 |