| NPI | 1508470923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: HI AMD-1073) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 8218) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2020-09-02 |
| Last Update Date | 2022-06-09 |