| NPI | 1487924486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8164391-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA0620) |
| 363A00000X Physician Assistant (Licence: WY PA837) | |
| Enumeration Date | 2012-01-06 |
| Last Update Date | 2024-04-26 |