| NPI | 1184149338 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07358) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10004486A) |
| Enumeration Date | 2017-08-09 |
| Last Update Date | 2024-08-12 |