| NPI | 1336802479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 5184) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: SC 4181) | |
| Enumeration Date | 2021-10-15 |
| Last Update Date | 2025-06-16 |