| NPI | 1114787405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 1816) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 10557) |
| Enumeration Date | 2024-03-21 |
| Last Update Date | 2025-06-12 |