| NPI | 1184261646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA7943) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA7943) |
| Enumeration Date | 2019-12-04 |
| Last Update Date | 2025-08-13 |