| NPI | 1780910547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1184) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 594) |
| Enumeration Date | 2009-10-28 |
| Last Update Date | 2020-09-10 |