| NPI | 1700033156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2014-0058) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 60632876) |
| Enumeration Date | 2008-08-27 |
| Last Update Date | 2023-02-15 |