| NPI | 1811474216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14116) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1153399) |
| Enumeration Date | 2018-07-27 |
| Last Update Date | 2025-05-09 |