| NPI | 1740897024 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA7791) | 
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical | 
| Enumeration Date | 2020-09-30 | 
| Last Update Date | 2025-01-07 |