| NPI | 1396612099 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110012047) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110012047) |
| Enumeration Date | 2025-10-20 |
| Last Update Date | 2026-06-16 |