| NPI | 1326420290 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05685) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 3937) |
| Enumeration Date | 2015-06-26 |
| Last Update Date | 2025-01-29 |