| NPI | 1801078654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA1068) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5123) |
| Enumeration Date | 2007-12-04 |
| Last Update Date | 2022-12-30 |