| NPI | 1730496977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2011-0012) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA00611) |
| 363A00000X Physician Assistant (Licence: FL PAT9105615) | |
| Enumeration Date | 2010-09-09 |
| Last Update Date | 2016-08-15 |