| NPI | 1447286943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY TL556) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA200064) |
| Enumeration Date | 2006-06-25 |
| Last Update Date | 2018-07-11 |