| NPI | 1447697735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: ID PA-1056) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA1429) |
| Enumeration Date | 2013-05-28 |
| Last Update Date | 2024-03-11 |