| NPI | 1912334699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NM PA2022-0048) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA2395) |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA60381426) | |
| Enumeration Date | 2013-09-26 |
| Last Update Date | 2023-08-02 |