| NPI | 1992215545 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1545) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA202158) |
| Enumeration Date | 2017-10-10 |
| Last Update Date | 2021-01-25 |