| NPI | 1982904421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063395) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003296) |
| Enumeration Date | 2010-11-01 |
| Last Update Date | 2022-05-09 |