| NPI | 1003897661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 631) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 631) |
| 363A00000X Physician Assistant (Licence: AZ 9900) | |
| 363A00000X Physician Assistant (Licence: OK 5119) | |
| Enumeration Date | 2005-11-10 |
| Last Update Date | 2025-05-05 |