| NPI | 1871586586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM 99-PA24) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 673) |
| Enumeration Date | 2005-08-26 |
| Last Update Date | 2016-08-11 |