| NPI | 1558765891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1265) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 5905) |
| Enumeration Date | 2014-10-15 |
| Last Update Date | 2022-04-13 |