| NPI | 1790958734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: HI AMD755) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2738) |
| Enumeration Date | 2008-04-10 |
| Last Update Date | 2022-10-12 |