| NPI | 1346575420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 4569) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 4569) | |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 4569) | |
| Enumeration Date | 2009-10-07 |
| Last Update Date | 2024-11-14 |