| NPI | 1144569765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 7844) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2292) |
| 363A00000X Physician Assistant (Licence: CO 3930) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TN 2292) | |
| Enumeration Date | 2013-02-01 |
| Last Update Date | 2022-12-02 |