| NPI | 1508644873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-13994) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-13994) |
| Enumeration Date | 2023-09-18 |
| Last Update Date | 2024-10-08 |