| NPI | 1083069793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 65833191206) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: CA 54658) |
| 363A00000X Physician Assistant (Licence: CA 54658) | |
| 363AS0400X Physician Assistant Surgical (Licence: WA PA60677483) | |
| Enumeration Date | 2016-05-01 |
| Last Update Date | 2024-05-02 |