| NPI | 1356422554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10001530A) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: FL PA000033-46) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2021-07-01 |