| NPI | 1972991321 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 099669) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2015-01-07 |
| Last Update Date | 2022-10-19 |