| NPI | 1811337017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: ID PA-2126) |
| Additional Taxonomies | 104100000X Social Worker (Licence: ID LMSW # 33052) |
| Enumeration Date | 2013-07-02 |
| Last Update Date | 2022-01-17 |