| NPI | 1912405564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-12849) |
| Enumeration Date | 2018-01-29 |
| Last Update Date | 2025-01-28 |