| NPI | 1427303478 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1181) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA1361) |
| Enumeration Date | 2012-07-16 |
| Last Update Date | 2021-12-06 |