| NPI | 1508872763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2055) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 1071708) |
| Enumeration Date | 2006-07-31 |
| Last Update Date | 2024-12-03 |