| NPI | 1689926693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA1728) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015798) |
| Enumeration Date | 2012-10-15 |
| Last Update Date | 2017-09-28 |