| NPI | 1922611599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9693) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PR 1222) |
| 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: WI 20-151) | |
| Enumeration Date | 2020-08-25 |
| Last Update Date | 2023-11-27 |