| NPI | 1548699481 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110009826) |
| Enumeration Date | 2013-11-01 |
| Last Update Date | 2025-03-10 |