| NPI | 1568974632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2570) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 6821) |
| Enumeration Date | 2017-10-30 |
| Last Update Date | 2023-08-21 |