| NPI | 1265887772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2167) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 52212) |
| Enumeration Date | 2016-05-03 |
| Last Update Date | 2026-04-10 |