| NPI | 1760454235 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PA1009) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 2028) |
| 363AS0400X Physician Assistant, Surgical (Licence: GA 4149) | |
| Enumeration Date | 2006-02-07 |
| Last Update Date | 2024-03-07 |