| NPI | 1790568509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9876) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 1375) |
| Enumeration Date | 2023-08-15 |
| Last Update Date | 2023-08-18 |