| NPI | 1376810689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ PA-7035) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-954) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2011-12-01 |
| Last Update Date | 2024-04-22 |