| NPI | 1528676202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 9771961) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NV PA2509) |
| Enumeration Date | 2020-07-17 |
| Last Update Date | 2025-09-03 |