| NPI | 1306874623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1342) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 2557) |
| Enumeration Date | 2006-06-28 |
| Last Update Date | 2021-07-20 |