| NPI | 1811909302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IN 10000336A) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 2941) |
| 363A00000X Physician Assistant (Licence: NM PA2018-0005) | |
| Enumeration Date | 2006-08-12 |
| Last Update Date | 2022-07-07 |