| NPI | 1972202257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0009865) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 4926) |
| Enumeration Date | 2023-02-27 |
| Last Update Date | 2025-04-09 |