| NPI | 1588175996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6936) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA101012) |
| 363A00000X Physician Assistant (Licence: CO PA.0008836) | |
| 363A00000X Physician Assistant (Licence: WA PA61604771) | |
| 363A00000X Physician Assistant (Licence: NC 0010-14662) | |
| Enumeration Date | 2017-10-12 |
| Last Update Date | 2024-10-11 |