| NPI | 1942183595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 2635PA) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL TPPA1014) |
| Enumeration Date | 2025-07-30 |
| Last Update Date | 2026-06-07 |