| NPI | 1740536374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 6128829-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1940) |
| Enumeration Date | 2012-08-01 |
| Last Update Date | 2026-04-02 |