NPI | 1720004740 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PA732) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 25769) |
363A00000X Physician Assistant (Licence: AK PADA1193) | |
Enumeration Date | 2006-07-14 |
Last Update Date | 2023-01-04 |