| NPI | 1154411817 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 4039) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MA AP1113) |
| Enumeration Date | 2006-10-13 |
| Last Update Date | 2025-01-06 |