| NPI | 1508304684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2021-0043) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 3220) |
| 363A00000X Physician Assistant (Licence: HI PA2021-0043) | |
| 363A00000X Physician Assistant (Licence: HI AMD-847) | |
| Enumeration Date | 2017-02-08 |
| Last Update Date | 2021-09-07 |