| NPI | 1194021014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2145) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA209457) |
| 363A00000X Physician Assistant (Licence: UT 7886261-1206) | |
| Enumeration Date | 2011-02-10 |
| Last Update Date | 2024-03-07 |