| NPI | 1093448805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 3682) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0007928) |
| Enumeration Date | 2022-07-08 |
| Last Update Date | 2026-07-29 |