| NPI | 1346541448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 11030) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11262) |
| 363AS0400X Physician Assistant, Surgical (Licence: NM PA2019-0031) | |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2010-11-05 |
| Last Update Date | 2026-08-18 |