| NPI | 1134697477 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1734) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 11045201-1206) |
| Enumeration Date | 2018-11-05 |
| Last Update Date | 2026-03-11 |