| NPI | 1760842868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AR PA-130) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 7896) |
| Enumeration Date | 2016-03-02 |
| Last Update Date | 2025-03-04 |