NPI | 1982954913 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CT 2793) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020734) |
363A00000X Physician Assistant (Licence: WA PA61060288) | |
Enumeration Date | 2012-09-18 |
Last Update Date | 2021-06-16 |