| NPI | 1336499730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1250) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 5210) |
| Enumeration Date | 2012-09-12 |
| Last Update Date | 2020-07-30 |