| NPI | 1134589955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 59909) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2019021924) |
| 363A00000X Physician Assistant (Licence: KS 15-02218) | |
| 363A00000X Physician Assistant (Licence: PA MA058130) | |
| Enumeration Date | 2016-03-07 |
| Last Update Date | 2022-12-27 |