| NPI | 1760787766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MT 58888) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AK 966) |
| Enumeration Date | 2011-01-21 |
| Last Update Date | 2023-11-27 |