| NPI | 1639144702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 1876) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 270990-1206) |
| Enumeration Date | 2006-02-21 |
| Last Update Date | 2015-12-11 |