| NPI | 1962512293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK PADA1183) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2005-0017) |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2021-06-04 |