| NPI | 1245525344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD C0004466) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 4866) |
| Enumeration Date | 2011-06-16 |
| Last Update Date | 2025-09-18 |