| NPI | 1477045177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1617) |
| Enumeration Date | 2018-05-30 |
| Last Update Date | 2022-09-08 |