| NPI | 1912182775 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA1467) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 3823) |
| Enumeration Date | 2007-12-29 |
| Last Update Date | 2023-07-07 |