| NPI | 1699861732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WY 115) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA1001) |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2010-03-31 |