| NPI | 1134580079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 123456) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 6345) |
| Enumeration Date | 2016-03-18 |
| Last Update Date | 2025-11-12 |