| NPI | 1831857168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 5306) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2021-0113) |
| Enumeration Date | 2021-12-03 |
| Last Update Date | 2023-04-05 |