| NPI | 1851649032 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA1639) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10001465A) |
| 363A00000X Physician Assistant (Licence: OR PA211540) | |
| 363A00000X Physician Assistant (Licence: WA PA61358281) | |
| Enumeration Date | 2012-08-21 |
| Last Update Date | 2024-01-24 |