| NPI | 1124203500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV USAF Federal PA) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA975) |
| Enumeration Date | 2008-01-04 |
| Last Update Date | 2014-09-11 |