| NPI | 1467110890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 8614) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: WI 22-423) |
| 291U00000X Clinical Medical Laboratory (Licence: IL 109977) | |
| 363AM0700X Physician Assistant, Medical (Licence: FL TPPA485) | |
| 363AM0700X Physician Assistant, Medical (Licence: PR 683-P.A.) | |
| Enumeration Date | 2021-12-02 |
| Last Update Date | 2025-06-30 |