| NPI | 1386027621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2020-0093) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.004413) |
| Enumeration Date | 2015-07-06 |
| Last Update Date | 2020-12-14 |