| NPI | 1780928580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA1027) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA160595) |
| Enumeration Date | 2012-11-16 |
| Last Update Date | 2023-09-28 |