| NPI | 1346685807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2017-0013) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 003744) |
| Enumeration Date | 2013-05-09 |
| Last Update Date | 2019-02-21 |