| NPI | 1790439016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063005) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005865) |
| Enumeration Date | 2022-02-06 |
| Last Update Date | 2023-01-06 |