| NPI | 1619362480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2296) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 10816599-1206) |
| Enumeration Date | 2015-03-30 |
| Last Update Date | 2022-08-26 |