| NPI | 1336994110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 102105) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 10004) |
| 363A00000X Physician Assistant (Licence: PR 1983) | |
| Enumeration Date | 2024-04-23 |
| Last Update Date | 2024-12-06 |