| NPI | 1851624340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1399) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 580) |
| Enumeration Date | 2009-09-15 |
| Last Update Date | 2026-01-14 |