| NPI | 1902284664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 7557) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA225151) |
| Enumeration Date | 2015-05-14 |
| Last Update Date | 2025-07-11 |