| 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 | 2026-06-03 |