| NPI | 1164484952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA2914) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2014-0095) |
| Enumeration Date | 2006-04-05 |
| Last Update Date | 2025-07-21 |