| NPI | 1740929306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 11904) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 11904) |
| Enumeration Date | 2022-06-01 |
| Last Update Date | 2025-06-30 |