| NPI | 1063193084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA065385) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-07-31 |
| Last Update Date | 2024-02-12 |