| NPI | 1932389087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MT 67783) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10005311) |
| 363AM0700X Physician Assistant, Medical (Licence: CO PA.1234567) | |
| Enumeration Date | 2007-11-06 |
| Last Update Date | 2025-07-30 |