| NPI | 1952308967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PA797) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004156) |
| Enumeration Date | 2005-07-05 |
| Last Update Date | 2025-07-31 |