| NPI | 1134572738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA61515049) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NM PA2016-0049) |
| Enumeration Date | 2016-07-19 |
| Last Update Date | 2024-05-08 |