| NPI | 1003330036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 088343) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA 088343) |
| Enumeration Date | 2017-08-01 |
| Last Update Date | 2024-10-30 |