| NPI | 1467735621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: UT 9210417-1206) |
| 363AM0700X Physician Assistant Medical (Licence: AZ 4893) | |
| Enumeration Date | 2011-09-23 |
| Last Update Date | 2024-04-16 |