| NPI | 1316580913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TN 4183) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 9848) |
| Enumeration Date | 2019-10-26 |
| Last Update Date | 2023-06-06 |