| NPI | 1639108004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 087087) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1436) |
| 363A00000X Physician Assistant (Licence: WA PA10004070) | |
| 363A00000X Physician Assistant (Licence: OR PA162693) | |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2022-07-21 |