| NPI | 1760989032 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 1453) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 123758) |
| 363A00000X Physician Assistant (Licence: NE 3110) | |
| Enumeration Date | 2018-04-12 |
| Last Update Date | 2024-11-27 |