| NPI | 1386147957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 11596) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA1960) |
| Enumeration Date | 2018-03-09 |
| Last Update Date | 2026-04-08 |