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 |