| NPI | 1184122756 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-1666) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 10527550-1206) |
| 363AM0700X Physician Assistant, Medical (Licence: UT 10527550-8906) | |
| 363AM0700X Physician Assistant, Medical (Licence: OR 186220) | |
| Enumeration Date | 2018-01-29 |
| Last Update Date | 2020-04-15 |