| NPI | 1952933160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007696) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-02-05 |
| Last Update Date | 2025-05-28 |