| NPI | 1811491400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA059724) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA OA004443) |
| Enumeration Date | 2018-03-20 |
| Last Update Date | 2025-07-09 |