| NPI | 1972955276 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 3080) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2877) |
| 363AM0700X Physician Assistant Medical | |
| Enumeration Date | 2016-07-11 |
| Last Update Date | 2022-04-19 |