| NPI | 1336488378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1339) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MP 83) |
| 363AM0700X Physician Assistant, Medical (Licence: ID PA-1339) | |
| Enumeration Date | 2013-02-12 |
| Last Update Date | 2024-03-19 |