| NPI | 1720167042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 3490) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM 2004-0038) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 3490) | |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 3490) | |
| Enumeration Date | 2006-11-06 |
| Last Update Date | 2016-01-14 |