| NPI | 1619451150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA.1398) |
| Enumeration Date | 2018-09-20 |
| Last Update Date | 2025-08-08 |