| NPI | 1245058775 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 10345) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PR 1871-PA) |
| Enumeration Date | 2024-10-02 |
| Last Update Date | 2024-10-02 |