| 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 |