| NPI | 1922414598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1908) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11684) |
| Enumeration Date | 2014-07-03 |
| Last Update Date | 2022-11-08 |