| NPI | 1326023417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA1844) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-614) |
| 363AM0700X Physician Assistant, Medical (Licence: ID PA-614) | |
| 363AS0400X Physician Assistant, Surgical (Licence: ID PA-614) | |
| Enumeration Date | 2005-12-12 |
| Last Update Date | 2019-01-18 |