| NPI | 1285983247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 5174) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11081) |
| Enumeration Date | 2012-09-06 |
| Last Update Date | 2025-12-04 |