| NPI | 1407464381 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: VA 0110007672) | |
| Enumeration Date | 2020-07-16 |
| Last Update Date | 2025-01-21 |