| NPI | 1376654319 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10001155A) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 85002740) |
| 363A00000X Physician Assistant (Licence: NC 0010-00966) | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2024-03-06 |