| NPI | 1730499054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA-2022-0116) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: KY PA1594) |
| 363AS0400X Physician Assistant Surgical (Licence: TN 2800) | |
| 363AS0400X Physician Assistant Surgical (Licence: MT 103693) | |
| Enumeration Date | 2010-10-20 |
| Last Update Date | 2023-12-06 |