| NPI | 1154937001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WY PT1013) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 105753) |
| 363AS0400X Physician Assistant, Surgical (Licence: NE 2477) | |
| Enumeration Date | 2020-09-16 |
| Last Update Date | 2022-07-22 |