| NPI | 1063821700 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MT MED-PAC-LIC-103548) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA10358) |
| 363A00000X Physician Assistant (Licence: NM PA2020-0044) | |
| 363A00000X Physician Assistant (Licence: WV 2648) | |
| 363A00000X Physician Assistant (Licence: WI 7212) | |
| Enumeration Date | 2014-08-06 |
| Last Update Date | 2025-01-08 |