| NPI | 1760823900 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: OR PA213593) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 055-0031643) |
| 363A00000X Physician Assistant (Licence: WY PA662) | |
| 363A00000X Physician Assistant (Licence: WA PA60485019) | |
| 363A00000X Physician Assistant (Licence: VA 0110008975) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-07-16 |
| Last Update Date | 2024-05-15 |