| NPI | 1710666532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13454) |
| Additional Taxonomies | 208VP0000X Pain Medicine, Pain Medicine (Licence: NC 0010-13454) |
| Enumeration Date | 2023-07-18 |
| Last Update Date | 2024-07-19 |