| NPI | 1649821646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2045) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 13178) |
| Enumeration Date | 2019-09-23 |
| Last Update Date | 2024-11-19 |