| NPI | 1295037844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2065) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: ID PA-2065) |
| 363A00000X Physician Assistant (Licence: WA PA60191252) | |
| 363AM0700X Physician Assistant, Medical (Licence: ID PA-2065) | |
| Enumeration Date | 2010-12-01 |
| Last Update Date | 2023-12-22 |