| NPI | 1194934018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4821) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 11135) |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2026-06-03 |