| NPI | 1639443880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA1377) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NV PA0235) |
| Enumeration Date | 2012-03-06 |
| Last Update Date | 2020-07-21 |