| NPI | 1164109112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 001423) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 001423-PA) |
| 363AM0700X Physician Assistant, Medical (Licence: 001423-PA) | |
| Enumeration Date | 2023-06-30 |
| Last Update Date | 2023-06-30 |