| NPI | 1285785782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID PA-146) |
| 208000000X Pediatrics (Licence: ID pa146) | |
| 208D00000X General Practice (Licence: ID PA146) | |
| Enumeration Date | 2007-01-13 |
| Last Update Date | 2022-03-25 |