| NPI | 1811407927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110006350) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA059291) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA059291) | |
| Enumeration Date | 2017-10-03 |
| Last Update Date | 2025-09-25 |