| NPI | 1083917355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PA1104) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: UT 7821385-1206) |
| Enumeration Date | 2010-12-08 |
| Last Update Date | 2024-11-05 |