| NPI | 1063828291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WY PA600) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NM PA2018-0013) |
| 363AM0700X Physician Assistant, Medical (Licence: UT 7817012-1206) | |
| Enumeration Date | 2014-07-09 |
| Last Update Date | 2020-09-30 |