| NPI | 1053991034 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10946) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL 1698) |
| Enumeration Date | 2021-04-13 |
| Last Update Date | 2022-03-08 |