| NPI | 1790188498 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4605-23) |
| Additional Taxonomies | 376K00000X Nurse's Aide (Licence: WI 3633250) |
| Enumeration Date | 2014-10-08 |
| Last Update Date | 2025-10-07 |