| NPI | 1760568018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601004896) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA21868) |
| 363A00000X Physician Assistant (Licence: CO PA.0005320) | |
| 363A00000X Physician Assistant (Licence: AR PA-465) | |
| 363A00000X Physician Assistant (Licence: MT 570) | |
| 363AM0700X Physician Assistant, Medical (Licence: CO PA.0005320) | |
| Enumeration Date | 2006-10-30 |
| Last Update Date | 2019-10-03 |