| NPI | 1922320407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA21071) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2011-0016) |
| 363A00000X Physician Assistant (Licence: UT 7593560-1206) | |
| 363A00000X Physician Assistant (Licence: WA PA60299193) | |
| Enumeration Date | 2010-02-24 |
| Last Update Date | 2014-02-05 |