| NPI | 1790944312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA-053831) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 1029) |
| 363A00000X Physician Assistant (Licence: IA 002288) | |
| 363A00000X Physician Assistant (Licence: MN 11085) | |
| Enumeration Date | 2008-06-09 |
| Last Update Date | 2023-10-27 |