| NPI | 1912279928 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 4624) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50004048) |
| 363A00000X Physician Assistant (Licence: NV PA1853) | |
| 363A00000X Physician Assistant (Licence: OR PA164398) | |
| Enumeration Date | 2012-02-07 |
| Last Update Date | 2023-12-28 |