| NPI | 1881686590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-10604) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004050) |
| 363A00000X Physician Assistant (Licence: MT 299) | |
| Enumeration Date | 2005-08-18 |
| Last Update Date | 2020-09-23 |