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 |