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 |