| NPI | 1861565988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1287) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 2551) |
| 363A00000X Physician Assistant (Licence: ID 1287) | |
| Enumeration Date | 2006-11-16 |
| Last Update Date | 2023-04-12 |