| NPI | 1265167019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2303) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2022-07-17 |
| Last Update Date | 2022-09-08 |