| NPI | 1548693989 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PA579) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WY TL579) |
| Enumeration Date | 2013-08-20 |
| Last Update Date | 2020-09-01 |