| NPI | 1982082319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: GA 007458) |
| Enumeration Date | 2015-05-18 |
| Last Update Date | 2019-04-08 |