| NPI | 1508311085 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WY PT696) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601008520) |
| Enumeration Date | 2016-08-24 |
| Last Update Date | 2021-10-04 |