| NPI | 1790552776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: AZ 10674) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-12-08 |
| Last Update Date | 2024-10-07 |