| NPI | 1558090829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2551) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 12740505-1206) |
| Enumeration Date | 2022-06-10 |
| Last Update Date | 2023-08-10 |