| NPI | 1740376102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2011-0062) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA22153) |
| 363A00000X Physician Assistant (Licence: IL 085-002088) | |
| 363AM0700X Physician Assistant, Medical (Licence: ID PA-848) | |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2020-01-02 |