| NPI | 1588603542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 2719) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 2719) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 2719) | |
| Enumeration Date | 2006-06-05 |
| Last Update Date | 2023-10-11 |