| NPI | 1992064299 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03764) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014536-1) |
| Enumeration Date | 2012-05-08 |
| Last Update Date | 2012-12-31 |