| NPI | 1528438595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 3671435) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C05872) |
| Enumeration Date | 2015-10-02 |
| Last Update Date | 2025-05-16 |