| NPI | 1164824546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9120283) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA173943) |
| Enumeration Date | 2014-09-17 |
| Last Update Date | 2025-12-11 |