| NPI | 1427880673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010344) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-08-16 |
| Last Update Date | 2024-08-27 |