| NPI | 1912536301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PR 000512-P.A.) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 000512-P.A.) |
| Enumeration Date | 2020-04-07 |
| Last Update Date | 2025-08-06 |