| NPI | 1114793940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0009201) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0012005) |
| Enumeration Date | 2023-12-04 |
| Last Update Date | 2023-12-04 |