| NPI | 1356050447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2538) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 13077807-1206) |
| Enumeration Date | 2022-11-17 |
| Last Update Date | 2023-08-28 |