| NPI | 1942078845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13910) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2023-12-20 |
| Last Update Date | 2025-07-02 |