| NPI | 1578808333 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WY PT925) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5322) |
| 363A00000X Physician Assistant (Licence: WY PT925) | |
| 363AS0400X Physician Assistant, Surgical (Licence: ID PA-1379) | |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2012-12-05 |
| Last Update Date | 2021-04-15 |