| NPI | 1114436672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2317) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA184708) |
| Enumeration Date | 2017-09-27 |
| Last Update Date | 2022-09-13 |