| NPI | 1215612635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13973) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-06-21 |
| Last Update Date | 2025-06-18 |