| NPI | 1619758620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 5999) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA 338914) |
| Enumeration Date | 2023-10-06 |
| Last Update Date | 2024-12-12 |