| NPI | 1235443193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1255) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 002097) |
| Enumeration Date | 2010-08-03 |
| Last Update Date | 2017-03-17 |