| NPI | 1528747425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23385) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 963-P.A) |
| 363A00000X Physician Assistant (Licence: AZ 8930) | |
| Enumeration Date | 2023-07-17 |
| Last Update Date | 2023-07-17 |