| NPI | 1407472863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007130) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-2436) |
| Enumeration Date | 2020-06-22 |
| Last Update Date | 2025-07-22 |