| NPI | 1215019088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY 539) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002411) |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2021-08-10 |