| NPI | 1508920059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55499) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA05049) |
| 363AM0700X Physician Assistant, Medical (Licence: NV PA2459) | |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 8258) | |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2023-11-24 |