NPI | 1316475619 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SC 4916) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
363AM0700X Physician Assistant, Medical (Licence: GA 8405) | |
Enumeration Date | 2017-05-31 |
Last Update Date | 2025-06-26 |