| NPI | 1629677356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA061959) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA005536) |
| Enumeration Date | 2020-10-23 |
| Last Update Date | 2023-04-04 |