| NPI | 1104583582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: AZ 9645) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 1141) |
| Enumeration Date | 2021-11-20 |
| Last Update Date | 2024-09-05 |