NPI | 1588115059 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0004806) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA70033963) |
363A00000X Physician Assistant (Licence: AZ 11274) | |
363AM0700X Physician Assistant, Medical (Licence: MA PA102015) | |
Enumeration Date | 2016-10-20 |
Last Update Date | 2025-09-22 |