| NPI | 1396148326 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10494) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7337) |
| 363A00000X Physician Assistant (Licence: NM PA2014-0051) | |
| 363A00000X Physician Assistant (Licence: OK 4505) | |
| 363AM0700X Physician Assistant, Medical (Licence: NM PA2014-0051) | |
| 363AM0700X Physician Assistant, Medical (Licence: SC 3518) | |
| Enumeration Date | 2014-10-05 |
| Last Update Date | 2024-08-27 |