| NPI | 1982159141 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA058699) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9112761) |
| Enumeration Date | 2016-08-17 |
| Last Update Date | 2019-10-30 |