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IDENTITAS PEMILIK

Nama : Mardatillah Wiranata


No. Mahasiswa : N 111 17 152
Program : Internasional/Regional
Angkatan : 2012
Lulus Sarjana : 2017
Alamat/ No. Telp : Jl. Lagarutu No 1a Palu / 085241200997
Tanggal Masuk : 28 Mei 2018
Tanggal Keluar : 19 Agustus 2018
Catatan :
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Pembimbing Klinik Tanda Tangan Pemilik

dr. Andi Amsyar Praja, Sp. A Mardatillah Wiranata


NIP. 196508121995031002 N 111 17 152