| NPI | 1558014811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IA 111879) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 2723) |
| 363A00000X Physician Assistant (Licence: KY PA3384) | |
| 363A00000X Physician Assistant (Licence: IA PA3384) | |
| Enumeration Date | 2022-01-27 |
| Last Update Date | 2024-06-04 |