| NPI | 1851965578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 699PA) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 8516) |
| Enumeration Date | 2021-05-17 |
| Last Update Date | 2025-05-05 |