| NPI | 1629201249 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1177) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10001138A) |
| Enumeration Date | 2009-08-30 |
| Last Update Date | 2014-08-05 |