| NPI | 1588938724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 7803) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 01623) |
| 363AM0700X Physician Assistant, Medical (Licence: 1844) | |
| Enumeration Date | 2012-03-06 |
| Last Update Date | 2021-02-08 |