| NPI | 1467723569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA1531) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MN 1667) |
| 363AS0400X Physician Assistant, Surgical (Licence: MN 11078) | |
| Enumeration Date | 2012-01-20 |
| Last Update Date | 2015-04-15 |