| NPI | 1710110457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PT605) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA06310) |
| Enumeration Date | 2009-08-28 |
| Last Update Date | 2015-02-27 |