| NPI | 1265809024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PT786) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 9515819-8002) |
| Enumeration Date | 2015-08-27 |
| Last Update Date | 2018-09-17 |