| NPI | 1245846187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA2561) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA2561) |
| Enumeration Date | 2020-09-16 |
| Last Update Date | 2024-10-11 |