| NPI | 1740003805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110010546) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-11-06 |
| Last Update Date | 2024-11-26 |