| NPI | 1710279757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PT652) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015663) |
| Enumeration Date | 2011-05-10 |
| Last Update Date | 2015-12-02 |