| NPI | 1619425006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06640) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10003668A) |
| Enumeration Date | 2016-09-14 |
| Last Update Date | 2022-08-01 |