| NPI | 1770251514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: TN 4796) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2021-09-04 |
| Last Update Date | 2024-11-04 |