| NPI | 1770764136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1246) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 138794) |
| Enumeration Date | 2007-11-14 |
| Last Update Date | 2026-06-09 |