| NPI | 1497200539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA2107) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5814) |
| 363A00000X Physician Assistant (Licence: CT 3840) | |
| Enumeration Date | 2016-08-18 |
| Last Update Date | 2022-07-21 |