| NPI | 1134873490 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10004400A) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MS PA00610) |
| 363A00000X Physician Assistant (Licence: NC 0010-12136) | |
| 363A00000X Physician Assistant (Licence: KY PA3559) | |
| Enumeration Date | 2022-02-07 |
| Last Update Date | 2025-02-03 |