| NPI | 1548802416 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 3871481) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 57691) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2019-10-11 |
| Last Update Date | 2026-01-14 |