| NPI | 1053385054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NV PA751) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA-845) |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2024-06-06 |