| NPI | 1104428499 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: NY P129347) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 08787533) |
| 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: WI 18-172) | |
| 363A00000X Physician Assistant (Licence: NJ NJDCATEMP-001670) | |
| 363A00000X Physician Assistant (Licence: MO 2019028021) | |
| Enumeration Date | 2020-11-11 |
| Last Update Date | 2025-01-31 |