| NPI | 1194779611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 4799) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA600) |
| Enumeration Date | 2006-05-20 |
| Last Update Date | 2021-02-16 |