| NPI | 1275758427 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 772) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NE 772) |
| Enumeration Date | 2007-04-14 |
| Last Update Date | 2025-06-23 |