| NPI | 1548718802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.005300RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0007837) |
| 363AS0400X Physician Assistant, Surgical (Licence: MO 2016033542) | |
| 363A00000X Physician Assistant (Licence: NM PA2023-0010) | |
| Enumeration Date | 2016-09-15 |
| Last Update Date | 2023-10-10 |