| NPI | 1629337753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 2500) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO PA-3428) |
| 363AM0700X Physician Assistant, Medical (Licence: OK PA2500) | |
| Enumeration Date | 2012-05-09 |
| Last Update Date | 2021-03-22 |