| NPI | 1942550918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05904) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10001439A) |
| Enumeration Date | 2012-09-17 |
| Last Update Date | 2023-05-11 |