| NPI | 1164837126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: WA PA60820907) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NM PA2014-0037) |
| Enumeration Date | 2014-06-27 |
| Last Update Date | 2018-03-17 |