| NPI | 1164781555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: WY PT1073) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CO P.A.0005812) |
| 363AM0700X Physician Assistant Medical (Licence: TX PA07333) | |
| Enumeration Date | 2012-05-07 |
| Last Update Date | 2024-05-07 |