| 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 |