| NPI | 1871293514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9944) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR PA-1411) |
| Enumeration Date | 2023-03-09 |
| Last Update Date | 2023-11-11 |