| NPI | 1730165176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 7347) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 103161-1206) |
| 363AM0700X Physician Assistant, Medical (Licence: NV PA1673) | |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2019-03-27 |