| NPI | 1649610007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60807601) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9107240) |
| 363A00000X Physician Assistant (Licence: NE 1956) | |
| Enumeration Date | 2013-07-01 |
| Last Update Date | 2021-06-22 |