| NPI | 1225260078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8564) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA58388) |
| 363A00000X Physician Assistant (Licence: NM PA2021-0128) | |
| Enumeration Date | 2009-08-12 |
| Last Update Date | 2023-09-12 |