| NPI | 1225412943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1323) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2015-07-13 |
| Last Update Date | 2015-12-08 |