| NPI | 1134833445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QU0200X Clinic/Center, Urgent Care |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 5396) |
| Enumeration Date | 2023-01-11 |
| Last Update Date | 2026-06-04 |