| NPI | 1922342377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1054) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID GPA-054) |
| Enumeration Date | 2012-11-23 |
| Last Update Date | 2025-09-09 |