| NPI | 1780237404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK PA4777) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 026017) |
| 363A00000X Physician Assistant (Licence: MT med-pac-lic-103714) | |
| Enumeration Date | 2019-07-22 |
| Last Update Date | 2022-03-04 |