| NPI | 1225430226 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 5726) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA09395) |
| 363A00000X Physician Assistant (Licence: CO PA.0004728) | |
| 363AM0700X Physician Assistant, Medical (Licence: CO PA.0004728) | |
| Enumeration Date | 2014-09-22 |
| Last Update Date | 2022-03-18 |