| NPI | 1952619751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003993) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1349) |
| Enumeration Date | 2010-09-15 |
| Last Update Date | 2023-12-03 |