| NPI | 1356951891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 11015) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR 1178659) |
| Enumeration Date | 2020-08-07 |
| Last Update Date | 2025-06-06 |