| NPI | 1710495023 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA60933) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-10956) |
| 363A00000X Physician Assistant (Licence: NY 021587) | |
| 363A00000X Physician Assistant (Licence: IL 085.010312) | |
| 363A00000X Physician Assistant (Licence: VA 0110011719) | |
| Enumeration Date | 2018-01-21 |
| Last Update Date | 2026-04-21 |