| NPI | 1356744890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PA728) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA - 1194) |
| 363A00000X Physician Assistant (Licence: OR PA176761) | |
| Enumeration Date | 2014-09-29 |
| Last Update Date | 2022-10-24 |