| NPI | 1588754162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1611) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 330483-1206) |
| Enumeration Date | 2006-10-13 |
| Last Update Date | 2020-06-16 |