| NPI | 1427726413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110009335) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: MI 5601010740) |
| Enumeration Date | 2021-09-02 |
| Last Update Date | 2025-07-23 |