| NPI | 1245832013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA2593) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2020039974) |
| Enumeration Date | 2020-11-16 |
| Last Update Date | 2022-03-31 |