| NPI | 1255603510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA 057046) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD c0004713) |
| 363A00000X Physician Assistant (Licence: OK 2552) | |
| Enumeration Date | 2012-02-02 |
| Last Update Date | 2025-01-22 |