| NPI | 1568719060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10002029A) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AM0700X Physician Assistant, Medical (Licence: UT 8375969) | |
| Enumeration Date | 2012-08-14 |
| Last Update Date | 2021-03-11 |