| NPI | 1629076237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NV PA979) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 1136) |
| 363AM0700X Physician Assistant, Medical (Licence: KY PA891) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NV PA 979) | |
| 363AM0700X Physician Assistant, Medical (Licence: VA 0110002760) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TN 1136) | |
| Enumeration Date | 2005-07-08 |
| Last Update Date | 2016-06-14 |