| NPI | 1417636549 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PR 001732-P.A.) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PACN140) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 10019) | |
| Enumeration Date | 2023-07-17 |
| Last Update Date | 2026-03-06 |