| NPI | 1376099184 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA198003) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10002151A) |
| Enumeration Date | 2016-08-31 |
| Last Update Date | 2021-02-17 |