| NPI | 1235100991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2166) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA-2166) |
| 363AM0700X Physician Assistant, Medical (Licence: NV PA939) | |
| Enumeration Date | 2006-01-31 |
| Last Update Date | 2024-05-15 |