| NPI | 1477204725 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11931) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2022-01-18 |
| Last Update Date | 2025-05-19 |