| NPI | 1720742984 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9115203) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 001011812) |
| Enumeration Date | 2021-10-25 |
| Last Update Date | 2024-06-27 |