| NPI | 1134694516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110006447) |
| Enumeration Date | 2018-10-11 |
| Last Update Date | 2025-01-06 |