| NPI | 1417039991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 3509) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10004871A) |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2025-07-24 |