| NPI | 1407572233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 11751) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 11751) |
| Enumeration Date | 2022-10-13 |
| Last Update Date | 2023-08-03 |