| NPI | 1366134991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 10460) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PR 1675-P.A.) |
| Enumeration Date | 2023-05-23 |
| Last Update Date | 2024-07-08 |