| NPI | 1215271267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2024-0077) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9106966) |
| 363A00000X Physician Assistant (Licence: IL 85008357) | |
| 363A00000X Physician Assistant (Licence: WI 5180) | |
| Enumeration Date | 2012-11-15 |
| Last Update Date | 2025-01-30 |