| NPI | 1700841277 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 155263) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA-289) |
| Enumeration Date | 2006-04-19 |
| Last Update Date | 2025-05-07 |