| NPI | 1962651927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110008678) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2008-09-15 |
| Last Update Date | 2025-11-12 |