| NPI | 1073375507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 1869) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL TPPA659) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 10575) | |
| Enumeration Date | 2024-01-30 |
| Last Update Date | 2025-01-23 |