| NPI | 1730706433 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061784) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MG6281670) |
| Enumeration Date | 2020-06-29 |
| Last Update Date | 2023-03-06 |