| NPI | 1841674405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-Lic-59289) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1264) |
| Enumeration Date | 2015-07-14 |
| Last Update Date | 2018-03-17 |