| NPI | 1538276373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PA1225) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA A10320) |
| Enumeration Date | 2006-08-25 |
| Last Update Date | 2024-06-28 |