| NPI | 1972290526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 10333) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PR 1636-P-A) |
| Enumeration Date | 2023-04-21 |
| Last Update Date | 2025-02-04 |