| NPI | 1720334543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: WY PA643) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CO PA.0003502) |
| 363AM0700X Physician Assistant Medical (Licence: NC 0010-04186) | |
| Enumeration Date | 2012-07-30 |
| Last Update Date | 2018-11-28 |