| NPI | 1326799958 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063306) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: DE C50011662) |
| 363A00000X Physician Assistant (Licence: DE C5-0011662) | |
| Enumeration Date | 2022-01-14 |
| Last Update Date | 2025-01-03 |