| NPI | 1588632236 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 520) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY 245) |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2023-11-27 |